| NPI | 1508200437 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TN 0000017553) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: KS 76170) |
| Enumeration Date | 2013-04-22 |
| Last Update Date | 2019-07-31 |